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Will the 2015 Country Specific Recommendations contribute to health equity?

EuroHealthNet analysis of the 2015 Country-Specific Recommendations (CSRs) regarding pensions, children and families, and health systems

1. Analysis of healthy life years and

retirement ages in light of the EU’s 2015

CSRs.

2. Do the 2015 CSRs have the

potential to improve health equity for

all children and families?

3. Do the 2015 CSRs help move

towards sustainable health systems?

Final version (includes updated 2015 statutory retirement / pension ages)

27/08/2015

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Acknowledgements

EuroHealthNet is a not-for-profit partnership of public bodies accountable for public health and

working from local to regional, national and international levels across Europe. Its mission is to help

build healthier communities and tackle health inequalities within and between European states. See:

www.eurohealthnet.eu.

EuroHealthNet is supported by the European Union Programme for Employment and Social

Innovation (EaSI 2014-2020). This report does not necessarily reflect the position or opinion of the

European Commission.

Photo: “And you haven't been to your Doctor because?”, by Alex Proimos,

https://www.flickr.com/photos/proimos/6870109454/.

Authors: Linden Farrer, Leonardo Palumbo, Caroline Costongs, Ana Oliveira, Philip Hines.

Contact: Leonardo Palumbo, Health & Social Investment Senior Coordinator, EuroHealthNet

(l.palumbo@eurohealthnet.eu).

Address: EuroHealthNet, Rue de La Loi, 67, Bruxelles 1040, Belgium.

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Contents Acknowledgements ...................................................................................................................... 2

Executive Summary ...................................................................................................................... 5

1. The European Semester and Country-Specific Recommendations ........................................... 8

2. Analysis of healthy life years and retirement ages in light of the EU’s 2015 CSRs ................... 10

The importance of healthy life years to statutory retirement age and pensions ............................. 10

Methods ............................................................................................................................................ 12

Findings ............................................................................................................................................. 12

Placement of keywords in the 2015 CSRs ..................................................................................... 12

Analytic grouping of recommendations ........................................................................................ 12

Life expectancy (LE), healthy life years (HLY) and statutory retirement age (SR) ......................... 13

Discussion & Conclusions .................................................................................................................. 15

3. Do the 2015 CSRs have the potential to improve health equity for all children and families? . 18

The importance of recommendations relating to children and families .......................................... 18

Methods ............................................................................................................................................ 18

Main findings ..................................................................................................................................... 19

Question 1: Are children or their families on the agenda? ........................................................... 19

Question 2: “Does it involve increases in investment?” ............................................................... 20

Question 3: “Does it encourage an intersectoral approach?” ...................................................... 20

Question 4: “Are measures universal?” ........................................................................................ 20

Question 5: “Does it respond to disadvantage?” .......................................................................... 20

Question 6: “Does it encourage early intervention (from an early age)?” ................................... 21

Policy implications ............................................................................................................................. 21

Recommendations ............................................................................................................................ 23

4. Do the 2015 CSRs help move towards sustainable health systems? ...................................... 24

Introduction ....................................................................................................................................... 24

Links between access, primary care, community care and health promotion ................................. 24

Methods ............................................................................................................................................ 25

Findings ............................................................................................................................................. 25

Implications ....................................................................................................................................... 26

Health promotion .......................................................................................................................... 26

Primary care .................................................................................................................................. 27

Public health spending in the EU ................................................................................................... 27

Chronic diseases ............................................................................................................................ 29

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Mental health ................................................................................................................................ 29

National health strategies ............................................................................................................. 30

Recommendations ............................................................................................................................ 30

Annex 1. Additional tables, figures and annexes .......................................................................... 32

Annex 2. Pensions, healthy life years and statutory retirement ages in 2015 CSRs ........................ 37

Annex 3. Table of 2014 child and family CSRs .............................................................................. 38

Annex 4. Findings from previous research on equitable access to healthcare in Europe ................ 39

Annex 5. Health in the CSRs – Recommendation & Whereas sections .......................................... 40

Annex 6. Mental Health Spending across the EU .......................................................................... 43

Annex 7. Percentage of total public expenditure on mental health .............................................. 45

Notes and references ................................................................................................................. 46

Figures

Figure 1. Health in CSRs, 2011-2015 ..................................................................................................... 24

Figure 2. Health expenditure (% GDP) on prevention and public health services (2010, 2011, 2012) . 28

Figure 3. Cost per capita of all brain disorders (€PPP 2010) ................................................................. 29

Figure 4. Statutory retirement age, healthy life years and life expectancy, 2012, men ....................... 33

Figure 5. Statutory retirement age, healthy life years and life expectancy, 2012, women .................. 34

Figure 6. Healthy life years & early retirement, women, 2012. Malta is omitted as no figures available

for HLY ................................................................................................................................................... 35

Figure 7. Healthy life years & early retirement, men, 2012 .................................................................. 36

Figure 8. Percentage of total public expenditure on health spent on mental health ........................... 45

Tables

Table 1. Inclusion of “pension” and “retirement” keywords in the CSRs ............................................. 12

Table 2. Analytic groupings of pension-related CSRs ............................................................................ 13

Table 3. SR and HLY, by member state and women/men ..................................................................... 14

Table 4. Average different between healthy life years and statutory retirement ................................ 14

Table 5. Can member states increase SR without expecting women and men to continue working

after facing long-term activity limitation? ............................................................................................ 15

Table 6. Sources of questions used in children & families analysis ...................................................... 19

Table 7. Overview of questions and CSRs relating to children .............................................................. 21

Table 8. Overview of CSRs related to Council Recommendation on investing in children in 2014 ...... 22

Table 9. Areas of 2015 CSR relating to sustainable health systems ...................................................... 26

Table 10. Pension data .......................................................................................................................... 32

Table 11. Children and families in CSRs ................................................................................................. 38

Table 12. Mental health spending across the EU and Norway ............................................................. 44

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Executive Summary

The European Semester is the method by which the European Union co-ordinates implementation of

the Europe 2020 Strategy. The publication of the Country-Specific Recommendations (CSRs) is an

important point in the European Semester because it represents extensive consultation with

stakeholders at European and national levels, and a potential political programme for each member

state for the coming semester period.

EuroHealthNet has been monitoring the European Semester process for a number of years and

working with its members to argue for a stronger focus on public health, health promotion and

preventive services. EuroHealthNet’s two main objectives are to improve health between and within

European states and to tackle health inequalities.

This document brings together three linked analyses of the CSRs carried out by EuroHealthNet,

covering statutory retirement ages, children and families, and health promotion and sustainable

health systems. These three topics were selected based on EuroHealthNet’s previous work on

healthy and active ageing, child development, and health promotion. They represent areas amenable

to policy actions that can improve health and reduce health inequalities, and areas where inequities

in health could challenge policy reform and implementation.

In terms of statutory retirement ages, our analysis finds that:

1. Simple calls to increase statutory retirement/pension ages ‘in line with life expectancy’

need to be considered in the light of healthy life years and socio-economic status. Only 5

of the 13 countries receiving CSRs to increase retirement age can expect people to work

longer without facing long-term activity limitations; of these, only two would be able to

do so for both sexes. While activity limitations do not necessarily mean people cannot

continue working, they do suggest that adaptations and efforts are needed to support

workers to remain in the labour market.

2. Calls to increase statutory retirement are more realistic when they take account of the

different healthy life years of men and women. While there is some room to increase

retirement ages for women before they face long-term activity limitations, there is much

less scope to do so for men.

3. Lower socio-economic status (SES) groups have much lower HLY than higher SES groups,

so increasing statutory retirement ages without sensitivity to poor health status is likely

to affect already disadvantaged people disproportionally. Where available, data needs to

be examined in terms of equity before changing statutory retirement ages. Efforts should

also be made to make such data more widely available across the European Union.

4. More emphasis should be placed on supportive measures for older workers in the

workplace. Efforts also need to be stepped up to reduce the age discrimination faced by

older workers and encouraging employers to make adaptations to help older workers (or

those facing long-term activity limitations) to stay in employment. Sustaining older

people’s employment seems unlikely to succeed without the appropriate regulatory

environment and incentives and disincentives for employers and employees.

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5. Health promotion measures across the life course should be emphasised more in the

CSRs, particularly in those countries with the lowest healthy life years and greatest

differences between healthy life years and statutory retirement age.

In terms of children and families, our analysis finds that:

1. Too little emphasis is placed on children and families. The period of childhood is one of the

most important in determining future health, so greater emphasis in the CSRs on

implementing policies to improve child health would help ensure the future sustainability of

health and social systems and reduce early retirement.

2. Too little emphasis is placed on investment in early intervention. Just three countries

received a CSR on early intervention in 2015. This is worrying, given that early intervention is

widely considered one of the most effective ways to prevent health and social problems.

3. More time should be given to member states to implement reforms on child development;

policy priorities should not change on a yearly basis. CSRs pertaining to children and families

were more prominent in 2014 than in 2015. For example, in 2014 there were 18 CSRs on

inclusive education in 2014 and only 8 child-related CSRs in 2014. However, the (mostly

unchanged) rate of child poverty across the EU does not appear to warrant this reduced

policy emphasis.

4. Efforts should be made to address the lack of coherence between the problems identified

and solutions proposed. Indeed, many CSRs identify problems but do not propose solutions.

In terms of disease prevention, health promotion and sustainable health systems, our analysis

finds that:

1. CSRs related to health are characterised by a contradiction: they focus on cost-effectiveness,

performance and the efficient use of resources while failing to mention health promotion

and disease prevention, the importance of mental health or the need to address health

inequalities. Yet cost-effectiveness and efficient use of resources is not possible without

focusing on these latter issues.

2. We recommend an in-depth analysis of the underlying causes of ill health in countries with

poor performing health systems and low health outcomes. Guidance should be developed to

ensure financial sustainability of health systems without increasing out-of- pocket payments

that could be detrimental to health equity.

3. There is no reference to equity, health promotion, disease prevention or mental health. It is

widely acknowledged that 70-80% of healthcare costs are spent on chronic diseases. This

corresponds to €700 billion in the European Union and this figure is expected to increase in

the coming years. For these reasons, we recommend a much stronger focus on health

promotion measures, preventative and community services, and mental health. We

recommend monitoring equity of access to healthcare and conducting further analysis on

coverage rates.

4. Only 6 CSRs address on primary care, quality and access in 2015 despite their importance in

helping sustain high levels of health, and therefore high levels of employment and the ability

to work right up to retirement; 2 countries (FI, LV) received a recommendation on quality, 2

countries (BG, SK) received a recommendation on primary care, and 2 countries (LV, RO)

received a recommendation on accessibility.

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5. References to low levels of national health funding could partly be addressed through use of

structural funds. Structural funds remain a largely untapped resource for investing in public

health.

6. As there are four references to national health strategies, further exploration could be given

to how the European Semester can support national and sub-national health strategies.

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1. The European Semester and Country-Specific Recommendations

The European Semester is the method by which the European Union co-ordinates implementation of

the Europe 2020 Strategy. It was set up in the wake of the 2007/2008 financial and economic crisis,

which led to a sustained and deep economic crisis across the European Union and whose effects

continue to be felt today. The severity and impact of the crisis was at least partly exacerbated by lack

of economic oversight within the eurozone and ‘imbalances’ in certain member states’ economies

and labour markets1.

The European Semester is designed to detect, prevent and correct problematic economic trends,

such as excessive deficits and debts, and help prevent future imbalances and systemic risks from

appearing within the European Union. Every year, the European Commission analyses the fiscal and

structural reform policies of every member state, provides recommendations to member states and

monitors their implementation. As the economic crisis grew into a social and health crisis from 2010

onwards, commentators started pointing to divergent social situations across the EU (e.g. in terms of

poverty, unemployment); these, and the related rise of widespread eurosceptism, were seen as

threatening the existence of the European Union. The semester process consequently expanded

from concentrating mostly on macro-economic issues to including several social indicators within its

scope2.

The semester was instituted in 2011, though it is very much a work in progress. It starts with the

publication of the Annual Growth Survey and Joint Employment reports, which set the tone for the

rest of the semester. Following consultation with stakeholders at national and European levels, the

European Commission publishes Country Reports in February, which analyse the economic policies of

each member state. Following this, in May or June, the European Commission publishes Country-

Specific Recommendations (CSRs)3. The CSRs contain a resumé of relevant policy developments in

each country (the “Whereas” section), and a shorter set of recommendations (the

“Recommendations” section). The CSRs are subsequently discussed by the European Council and

voted through – usually without modification. The CSRs are politically binding, and sanctions can be

imposed under the excessive deficit and excessive imbalances procedures4, though

recommendations often cover areas of national competence (e.g. organisation of health systems,

social protection systems, entitlements to pensions) and the ‘bindingness’ of specific

recommendations is an issue of legal debate.

The CSRs are an important point in the European Semester because they represent (supposedly)

extensive consultation with stakeholders at European and national levels, and a potential political

programme for each member state for the coming semester period. In 2015 every member state

received a CSR, except for Cyprus and Greece – which are instead covered by Economic Adjustment

Programmes. This means that a total of 26 countries received CSRs. Ensuring that the CSRs are based

on evidence, are realistic, achievable, and concentrate on the most pressing issues that prevent the

growth of labour markets and economies is of considerable importance.

EuroHealthNet seeks to ensure that the social determinants of health across the life course,

equitable access to health services, as well as health promotion and disease prevention measures are

considered in discussions at EU and national levels about the EU 2020 strategy, the Social Investment

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Package and in developing health promotion systems. Our interest in the EU Semester is reinforced

by the fact that CSRs increasingly address questions related to the priorities and investments of

member states in the field of social affairs and health. As such, CSRs represent an opportunity to

ascertain the extent to which they may - or may not - contribute to health equity.

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2. Analysis of healthy life years and retirement ages in light of the EU’s 2015 CSRs

The importance of healthy life years to statutory retirement age and

pensions Europe is ageing rapidly. This is because fertility rates are generally below replacement rates, life

expectancies are increasing, and the ‘baby boomer’ generation, which resulted from an increase in

birth rates in the 1950s-60s, is entering retirement. One result of ‘demographic ageing’ is that the

ratio of workers to retirees is decreasing – or, in other words, the dependency ratio is increasing. The

dependency ratio (measured by the proportion of people aged 65 or above to those aged 15-64) is

projected to increase in the EU from 27.8% in 2013 to 50.1% in 20605. Another result of demographic

ageing is that health systems are being stretched, as older people generally require more medical

and social care than younger people. Public expenditure on health 2013-2060 in the EU is projected

to increase from 6.9 to 8% of GDP as a result of demographic ageing6. Taken together, these two

figures suggest significantly increased demands for care and pensions to be paid for by a dwindling

taxable employee base.

Given the situation, it is not surprising that increased attention has recently been paid to healthy

ageing. One example of this was the 2012 European Year for Active Ageing and Solidarity between

Generations7. Much emphasis is placed on the importance of adopting healthy lifestyles among older

people (e.g. smoking, drinking, diet, or exercise), but health is determined across the life course and

adversities in (for instance) early childhood and employment strongly determine whether people

‘age healthily’ or not. Despite the political attention, just 3% of total spending on health goes to fund

health promotion8, and it is therefore debatable how influential healthy ageing has really been in

terms of setting the political agenda.

There can be no debate, however, about the attention paid by CSRs to reducing the costs associated

with retirement9. In 2014, for instance, 16 member states received a CSR related to pension reform.

This is because pensions represent a huge financial liability to member states. Greece, for example,

spent 17.5% of GDP on pensions in 2012 - more than any other country -, while in the same year

Italy, France and Austria spent over 15%10. Indeed, almost every EU member state spent more than

7.5% of GDP on pensions in 201211.

Measures to reduce spending associated with retirement and pensions have included: harmonising

the statutory retirement age between men and women, reducing possibilities for early retirement,

reducing the amounts paid to beneficiaries, tightening eligibility criteria for the allocation of invalidity

pensions and aligning statutory retirement ages to life expectancy (LE). This final measure is often

invoked on the basis of the argument that people are living longer, so they should work longer too.

But do calls to increase retirement ages take into account long-term activity limitations that come

with ageing? These could include limitations on the kinds of job tasks someone can carry out or even

preclude employment completely.

The aim of this EuroHealthNet CSR Review is to compare statutory retirement ages (SR) in each

member state with an indicator called ‘Healthy Life Years’ (HLY)12. HLY measures how many years a

person can expect to live without a long-term limitation on activity. By analysing these figures, we

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hope to shed light on whether the recommendations in the 2015 CSRs expect people to continue

working after they face long-term activity limitations, or not.

In comparing these figures we have had to make choices about the data to select. Using the EC’s

2015 Ageing Report13 we chose (for simplicity’s sake) to compare statutory retirement ages in the

main public contributory schemes for private sector employees in non-hazardous professions. Some

pension schemes have more complex qualifying conditions, so where further specification was

necessary we chose 1955 as the date of birth, selected non-contributory pensions, and assumed a

woman had raised 2 children. In the instances of Slovakia and Sweden conflicting information was

found – figures were settled on using other information sources. In countries where there is no

statutory retirement age (e.g. UK) we took the age at which a person is entitled to old age pension;

note - we continue to use statutory retirement (SR) age as the shorthand term for these countries.

Our raw data can be found in Annex 2.

Four points should be made before proceeding.

First, the aim of this analysis is not to wade in on one side or another of the political, ethical or

individual-choice aspects of increasing statutory retirement ages, or whether people should continue

to work once they experience long-term activity limitations. Instead, we aim to examine the bare

‘facts’ of whether women and men in different countries are likely to have to remain in employment

despite facing long-term activity limitations as a result of implementing CSR recommendations.

Second, and something that must be born in mind throughout this report, HLYs vary markedly

between different socio-economic groups (as measured by occupational group, (maternal)

educational level, wealth, etc.). Although data are not yet available to routinely produce HLY by SES

across all member states of the European Union, data from individual member states point to

marked differences in HLY by SES14. In Belgium, for instance, the difference in HLY between males of

the highest and lowest levels of education is estimated to be up to 17 years15. Examining HLY by SES

is therefore crucial to determining the potential differential effects of policies. Nevertheless, the

‘average’ HLYs figures can be used as an indication of whether raising statutory retirement ages will

require people to work despite facing long-term activity limitations, and granularity can be sought

out by those wishing to examine HLY by SES in specific countries.

The third point is that there are acknowledged difficulties comparing figures pertaining to HLYs

across member states. This could help explain some of the more ‘extreme results’ seen in the data.

Nonetheless, the overall accuracy of HLY is considered high16. In addition, no other statistical

measure appears to take into account the subjective and mental health aspects of health and well-

being satisfactorily – two factors that have an indisputable bearing on whether someone remains in

the labour market or not. For this reason we consider it important to use HLY for this analysis.

Finally, health is determined across the life course, and health in older ages is determined by

conditions in early life. Two policy areas are therefore examined in separate CSR analyses in this

report, which could lead to better health in older age: families and early childhood, and health

promotion measures across the life course.

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Methods The following sources were consulted and used for analysis:

Life expectancy at birth in 2012, from HEIDI17.

Healthy life years at birth in 2012, from HEIDI; figures for Portugal were not available and

those for 2011 used instead18.

Statutory retirement age/pension age (PA) in 2015 (or closest year), from the 2015 Ageing

Report19.

Early retirement for reasons of health in 2012, from Eurostat20.

All 26 CSRs were downloaded from the European Commission (EC) website21 and searched for two

keywords: retirement and pensions22. These keywords were chosen on the basis of a review of the

2014 CSRs. When a keyword was found, the whole phrase was taken for analysis.

Findings

Placement of keywords in the 2015 CSRs

Nineteen out of 26 CSRs included one or more keyword related to retirement in 2015. Of these, 16

CSRs contained keywords in both the “Whereas” and “Recommendations” sections (Tab. 1).

Section of CSR # of occurrences Member state23

Neither section [no keywords returned] 7 EE, ES, HU, IE, SE, SK, UK

“Whereas”, but not “Recommendations” 3 CZ, DK, IT

Both “Whereas” & “Recommendations” 16 AT, BE, BG, DE, FI, FR, HR, LT, LU, LV, MT, NL, PL, PT, RO, SI

Table 1. Inclusion of “pension” and “retirement” keywords in the CSRs

We continued analysis on only those countries where keywords were contained in both the

“Whereas” and the “Recommendations” sections of the CSRs. Recommendations for these 16

member states took the form of short sentences (e.g. PT, SI), longer sentences (e.g. AT), multi-

sentence recommendations (e.g. HR), or even multiple recommendations (e.g. LT). In this way,

member states could receive more than one recommendation concerning pensions and retirement.

Analytic grouping of recommendations

Four analytic groups emerged in grouping the recommendations (Tab. 2). In some instances a

recommendation covered more than one analytic group, and some countries are consequently

represented in more than one group.

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Group CSR recommendation Member states (#)

1 Link to life expectancy / Encourage later retirement / Discourage early retirement

AT, BE, DE, FI, HR, LU, MT (7)

2 Ensure the sustainability of the pension system / Undertake reform of the pension system

AT, BE, FI, FR, LT, LV, PT, SI (8)

3 Equalise pension ages for men and women AT, RO (2)

4 ‘Other’: Examine pension fund portfolios / Examine adequacy of pensions / Examine pensions or retirement for certain occupational groups / Examine fairness of contributions for certain groups

BG, HR, LT, NL, PL (5)

N/A None [see Tab. 1: “Whereas”, but not “Recommendations” + “Neither”]

(CZ, DK, EE, ES, HU, IE, IT, SE, SK, UK (10))

Table 2. Analytic groupings of pension-related CSRs

Group 1 gathers recommendations to increase retirement age, often in line with life expectancy, and

reduce early retirement. Group 2 gathers recommendations to increase the “sustainability” of

pension systems or other general calls for ‘pension reform’. While some of Group 2’s possible policy

implications are distinct from Group 1’s (e.g. employee financing systems, levels of contributions,

fiscal policies) other possible policy implications could fall within Group 1. In other words, a

recommendation to ‘increase the sustainability of the pension system’ could be interpreted as a

recommendation to increase pension age. Only two countries are included in Group 3, which concern

equalisation of pension ages between men and women. The policy implications of this group can

again be considered as belonging to Group 1. Group 4 is a catch-all group, which contains

recommendations to ‘perform a portfolio screening’ (BG), examine pension adequacy (LT, HR),

reduce younger workers’ pension contributions (NL), and examine certain occupational groups’

pensions (PL, HR).

In total, 13 countries received at least one or more recommendation that falls in Groups 1-3: AT, BE,

DE, FI, FR, HR, LT, LU, LV, MT, PT, RO, SI.

Life expectancy (LE), healthy life years (HLY) and statutory retirement age (SR)

Graphs 1 & 2 show the SR, HLY and LE for women and men in all 28 EU member states (see Annex 1).

HLYs are higher for women (EU28 average, 62.5) than men (61.3) – a difference of 1.1 years. After

this, people continue to live but with a long-term activity limitation: in the EU28 this is 14.8 years for

men and 19.8 years for women. Consequently, LE is higher for women (EU28 average, 82.2) than

men (76.1) – a difference of 6.1 years. The average SR for women is 63, while for men it is 64.5 (a

difference of 1.5). On average women have a higher HLY, a higher LE and a lower SR.

For simplicity’s sake, we consider (+/-) 1.5 years of difference between SR and HLY as noteworthy.

Using this cut-off point and taking the figures for women we can see that SR is currently higher than

HLY in 15 countries (AT, DE, DK, EE, EL, FI, FR, IT, HU, LV, NL, PT, RO, SK, SI), the same as SR in 6 (BE,

CY, ES, LT, LU, UK) and below SR in 7 (HR, MT, BG, CZ, IE, PL, SE). Taking the figures for men, we can

see that SR is currently higher than HLY in 20 countries (AT, BG, CY, DE, DK, EE, EL, FI, FR, HR, HU, IT,

LT, LV, NL, PL, PT, RO, SI, SK), the same as SR in 6 countries (BE, CZ, ES, IE, LU, UK) and less than SR in

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2 (MT, SE). In short, in more countries than not men are unlikely to reach SR without facing long-term

activity limitations (Tab. 3).

Women (#) Men (#)

SR/PA higher than HLY (≤1.5 years)

AT, DE, DK, EE, EL, FI, FR, IT, HU, LV, NL, PT, RO, SK, SI (15)

AT, BG, CY, DE, DK, EE, EL, FI, FR, HR, HU, IT, LT, LV, NL, PL, PT, RO, SI, SK (20)

SR/PA same as HLY (+/- 1.5 years)

BE, CY, ES, LT, LU, UK (6) BE, CZ, ES, IE, LU, UK (6)

SR/PA below HLY (≥1.5 years)

HR, MT, BG, CZ, IE, PL, SE (7) MT, SE (2)

Table 3. SR and HLY, by member state and women/men

For women the 5 countries with the greatest ‘gaps’ between SR and HLY are Slovenia (-9.4), Finland

(-8.8), Slovakia (-7.9), Portugal (-7.4), the Netherlands (-6.3). For men the 5 countries are Estonia (-

9.9), Slovakia (-8.6), Slovenia (-8.5), Germany (-7.9) and Finland (-7.7). The 5 countries with the

greatest positive difference for women between SR and HLY for women are Malta (10.4), Sweden

(5.6), Bulgaria (5.), Czech Republic (4.4) and Croatia (3.7). Just 4 had a ‘positive’ difference for men

between SR and HLY: Malta (9.8), Sweden (5.9) Luxembourg (0.8) and Ireland (0.1). Only Malta and

Sweden could increase SR up to HLY for both sexes without women facing long-term activity

limitations.

Are there differences in HLY and SR between countries that received a CSR to increase SR (Groups 1-

3), and those countries that did not?

As indicated below in Tab. 4, the average difference between HLY and SR in countries that did receive

a CSR was -4.0 for men and -1.8 for women. By contrast, countries that did not receive a CSR to

increase pension ages had an average difference between HLY and SR was -2.9 for men and -0.6 for

women. Worryingly, at least in terms of member states’ capacities to implement the CSRs, this

indicates that countries that received a CSR are less likely to be able to fulfil them than those that did

not, or in any case, will require a greater proportion of workers to continue working well after they

experience long-term activity limitations.

Average (diff.

SR/HLY), Men

Average (diff. SR/HLY), Women

Received a recommendation to increase SR (Analytic groups 1-3) -4.0 -1.8

Did not receive a recommendation to increase SR -2.9 -0.6

Table 4. Average different between healthy life years and statutory retirement

Moving now to the 13 countries that received a CSR to increase statutory retirement/pension age

(Tab. 5 & Fig. 1):

8 countries (AT, DE, FI, RO, FR, LV, PT, SI) already have SR after end of HLY.

3 countries (BE, HR, LT) already have SR after HLY for men, but not for women.

2 countries (LU, MT) currently have SR before end of HLY for men and women.

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Table 5. Can member states increase SR without expecting women and men to continue working after facing long-term activity limitation?

Discussion & Conclusions There are substantial differences between life expectancy and HLY in the European Union; men live

14.8 years outside of healthy life years before reaching life expectancy, while women tend to live for

19.8 years outside of healthy life years before reaching life expectancy (see Graphs 1 & 2). There are

also substantial differences between statutory retirement ages and healthy life years in the majority

of EU countries for men, and in a significant number of EU countries for women. This indicates that

men and women in many countries probably already work after facing long-term activity limitations.

Additional scatterplot graphs have been created separately for men and women showing healthy life

years and early retirement for health reasons (Graphs 3 & 4). They suggest that while there is no

relationship between early retirement and healthy life years for women, there is a clear but fairly

weak relationship between early retirement and healthy life years for men. These statistics should be

treated with caution, but the relationship for men (and lack thereof for women) suggest that men’s

higher statutory retirement age coupled with lower healthy life years results in an increased

likelihood that men take early retirement for health reasons.

Policy makers are faced with several potential policy options. These include:

Increasing pension ages despite the evidence produced here. While some people may be

able to continue working despite long-term activity limitations, there is a risk is that many

will not be able to do so. As access to early retirement (or other benefits) is restricted, the

danger is that increasing numbers of older people will have to rely on their own resources

(rather than those of the state) to live – potentially increasing poverty, homelessness, social

exclusion and health problems.

Increasing pension ages, but only in those member states and for sexes that are healthy

enough. This avoids the dangers of pushing people into poverty, but precludes increasing

Diff. SR HLY men

Diff. SR HLY women

Based on HLY, can member state increase retirement age without expecting men and women to continue working after facing long-term activity limitations?

AT -4.8 -2.5 No

BE -0.6 0.4 Yes, but only for women

DE -7.9 -3.9 No

FI -7.7 -8.8 No

HR -3.0 3.7 Yes, but only for women

LU 0.8 1.4 Yes

MT 9.8 10.4 Yes

RO -7.2 -2.1 No

LT -6.4 0.6 Yes, but only for women

FR -4.4 -3.1 No

LV -7.5 -3.2 No

PT -5.3 -7.4 No

SI -8.5 -9.4 No

16

statutory retirement age in many EU member states. Availability of data for healthy life years

by socio-economic group would help indicate the equity impacts of such changes.

Implementing measures to support people to remain in the labour market despite long-

term activity limitations. A strong argument can be made that health problems should not

inhibit people from being able to work – though a suitable policy environment is required to

make this happen, and this could entail certain costs (e.g. retraining, adaptations). Similarly,

work can play a protective role in health, given the right working conditions. There are

likewise strong arguments why people facing long-term activity limitations should not be

compelled to continue working, at the very least because they may not be able to do so,

perhaps because their limitation is severe or because the workplace cannot be adapted.

Measures will need to be targeted at workers and employers, and could include employment

regulations, tax incentives, information campaigns and greater provision of occupational

health services. Efforts will be needed to encourage workers to stay in the labour market, to

encourage employers to make their work environments healthier and adapted to those

facing activity limitations. Additional measures may be needed to incentivise employers to

avoid discriminatory practices (e.g. age or health discrimination).

Making greater efforts to improve public health across the life course. This could ‘push

back’ the age at which people start facing activity limitations. Over time, this would likely

raise HLYs and allow policy makers to increase SR with greater expectation that people would

remain in employment. EU member states currently put far too little emphasis on health

promotion – so considerably more could be done. Those countries with the lowest HLYs

appear to be those most in most need of health promotion. Although health promotion

efforts concerning lifestyle issues and diet come to mind, efforts need to be made during

important points of the life course, such as early childhood, employment and working

conditions, and income and social protection24.

How could the CSRs be improved in 2016?

First, simple calls to increase SR ‘in line with life expectancy’ need to be considered in the

light of HLY and socio-economic status. As we have seen, only 7 of the 13 countries receiving

CSRs related to increasing retirement ages can expect people to work longer without facing

long-term activity limitations; of these, only three would be able to do so for both sexes. It

should be noted that countries where people are already more likely to face long-term

activity limitations before they reach SR are more likely to receive a recommendation to

increase statutory retirement age than those where the workforce is healthier. This raises

additional questions of equity, given that not all people facing activity limitations are likely to

be able to remain in work.

Second, calls to increase statutory retirement are more realistic when they take account of

the different HLYs of men and women. While there is some room to increase retirement

ages for women before they face activity limitations, there is much less scope to do so for

men.

Third, lower socio-economic status (SES) groups have much lower HLY than higher SES

groups. Increasing statutory retirement ages could therefore have highly iniquitous effects.

Where available, data needs to be examined in terms of equity before changing statutory

17

retirement ages. Efforts should also be made to make such data more widely and regularly

available for all EU member states.

Fourth, more emphasis could be placed on supportive measures for older workers in the

workplace. This would need to address the discrimination faced by older workers and

adaptive measures that employers would need to implement. Sustaining older people’s

employment seems unlikely to succeed without the appropriate regulatory environment and

incentives and disincentives for employers and employees.

Fifth, health promotion measures across the life course should be emphasised more in the

CSRs, particularly in those countries with the worst HLYs and greatest differences between

HLY and SR.

18

3. Do the 2015 CSRs have the potential to improve health equity for all children and families?

The importance of recommendations relating to children and families The environment a child experiences, from the prenatal period through early childhood, can have a

profound influence on later life changes and outcomes. A loving, responsive, nurturing and

stimulating environment supports positive development in the early years, while problems at this

stage can have serious negative effects on the development of cognitive, communication and

language, and social and emotional skills25. Families are important in providing a loving and

supportive environment for children, which is conducive to child well-being. Indeed, as noted in the

United Nations Convention on the Rights of the Child, “the family, as the fundamental group of

society and the natural environment for the growth and well-being of all its members and particularly

children, should be afforded the necessary protection and assistance so that it can fully assume its

responsibilities within the community”26.

A recently published systematic review attested to the wide range of factors that are associated with

adverse child health and development outcomes: neighbourhood deprivation, lower parental

income/wealth, parental educational attainment, lower parental occupational social class, higher

parental job strain, parental unemployment, lack of housing tenure and household material

deprivation27. Policies that support children and families in these areas are likely lead to more

positive health and developmental outcomes, while those that make them worse are likely to have a

negative effect.

As the European Commission works towards recovery from the economic, financial and social crisis

that has affected the EU for the past half-decade, it announced its intention to lift 20 million people

out of poverty by 2020. Children were at greater risk of poverty or social exclusion in 2013 than the

rest of the population in 20 of the 28 EU member states, with an at-risk rate standing at 27.6% in the

EU2828. It is, then, relevant and necessary to find out whether Country-Specific Recommendations

(CSRs), issued by the EC in response to member states’ National Reform Programmes (NRPs), take

children and their families into consideration, as austerity measures and recession have taken a

considerable toll on households across the EU – in particular the most socio-economically vulnerable

households29. This analysis therefore aims to ascertain the scope and inclusiveness of CSRs related to

children and families, and to find out whether the suggested measures are a step in the right

direction in terms of improving health and reducing health inequalities.

Methods We use the outcomes of two FP7 research projects co-ordinated by EuroHealthNet to examine

whether the 2015 CSRs are likely to improve health and reduce health inequalities in children and

families.

Using the findings of the DRIVERS project - in particular the systematic review of interventions which

aim to improve child health30 and the project’s four principles by which policy makers can design

policies to reduce health - we selected questions from the GRADIENT project’s Gradient Evaluation

Framework (GEF) (Table 6). The GEF is a tool to help policy makers design and implement policies to

19

level up the gradient in health in children and families31. We then use these questions to analyse the

CSRs.

Question Type GEF source

DRIVERS source

1. Are children or their families on the agenda?

Filtering question

3. Whole systems approach DRIVERS ECD

2. Does it involve increases in investment?

Qualitative 3. Whole systems approach / 4. Scale and intensity

n/a

3. Does it encourage intersectoral action?

Qualitative 2. Intersectoral tools for all DRIVERS

4. Are measures universal? Qualitative 1. Universalism Principle 1

5. Does it respond to disadvantage?

Qualitative 1. Universalism Principle 2

6. Does it encourage early intervention (from an early age)?

Qualitative 3. Whole systems approach DRIVERS ECD

Table 6. Sources of questions used in children & families analysis

A keyword search was used to answer the first question. If a CSR included “child*”, “famil*”,

“household”, “single” or “breadw*” anywhere in the text, then we considered that children or their

families were on the agenda. This left us with 12 EU member states. It should be noted that there

were areas mentioned in tandem with children (such as education and poverty) which could have a

knock-on effect on family and child policies, but cannot be properly evaluated here (Groups 2-5,

Table 7). Both GEF gradient and the DRIVERS findings highlighted the importance of policies and

interventions aimed at children and their families. None of the CSRs appear to relate to empowering

family members to improve their situation.

Table 7. Areas of the recommendations

We continued analysis only for the 13 countries where children and families were on the agenda. For

these, we qualitatively assessed responses to Questions 2-7, with responses categorised as “yes” (Y)

or “no” (N).

Main findings

Question 1: Are children or their families on the agenda?

Thirteen countries received CSRs that did mention children and/or their families mentioned (AT, BG,

CZ, EE, ES, HU, IE, IT, MT, PL, RO, SK, UK). Thirteen countries received CSRs that did not mention

Group Area of CSR recommendation Member states (#)

1 Children and families AT, BG, CZ, EE, ES, IE, IT, NL, PT, RO, SE, SK, UK (13)

2 Low-income earners CZ, EE (2)

3 Education BG, HU, PL, RO, SK (5)

4 Employment AT, CZ, EE, IE, IT, MT, SK, UK (8)

5 Poverty ES, HU, IE, IT, RO (5)

N/A None [see Tab. 1: “Whereas”, but not “Recommendations” + “Neither”]

BE, DE, DK, FI, FR, HR, LT, LU, LV, NL, PT, SE, SI (13)

20

children and/or their families (BE, DE, DK, FI, FR, HR, LT, LU, LV, NL, PT, SE, SI); these were excluded

from further analysis.

Four countries had CSRs with children and families mentioned in the “Whereas” section but not in

the “Recommendations” section (IT, HU, MT, PL); these were excluded from further analysis. This left

9 countries which had CSRs with children and families mentioned in both “Whereas” and

“Recommendations” sections (AT, BG, CZ, EE, ES, IE, RO, SK, UK).

Question 2: “Does it involve increases in investment?”

There did not seem to be a clear trend in the recommendations. Investment in early child

development, family support, or early education was not explicitly mentioned for any country.

However, many recommendations could conceivably entail a need for increased investment. Due to

this implied investment, all countries with a CSR were classified as involving increases in investment.

Six countries (CZ, EE, IE, RO, SK & UK) received a recommendation related to improving access to

childcare services and 3 countries (BG, RO, & SK) on increasing participation in education. The quality

of services was addressed in recommendations to 5 countries (BG, EE, RO, SK, and UK).

Question 3: “Does it encourage an intersectoral approach?”

By an intersectoral approach we refer to policies and actions requiring the involvement of, and

collaboration between, more than one policy sectors. Only 3 countries (IE, ES, SK) received a CSR

encouraging a clear intersectoral approach. Recommendations concerning education did not appear

to promote the involvement of other sectors, so they were assigned a negative response to this

question.

The most clear intersectoral collaboration in 2015 is with employment policy and child issues. The

issue of women’s participation in the labour market was mentioned in the “Whereas” section of CSRs

for AT, CZ, SK and UK. However, only SK received a recommendation on this issue. This suggests that

there is recognition in the other 3 countries that this is a cause for concern, but that the situation will

merely be monitored. Spain received a recommendation to “Streamline minimum income and family

support schemes”, so this could entail links between social affairs and economic policy. IE is

recommended to “take steps to increase the work-intensity of households” [sic], which again appears

to imply an intersectoral approach.

Question 4: “Are measures universal?”

With this question, we sought to find out whether CSRs are aimed at children and families of all

socio-economic and cultural groups or if, on the other hand, they target specific groups. All the CSRs

that did not target specific groups were classified as universal. More than half of the analysed CSRs

presented themselves as universal as per the criteria explained above, while only two countries had

CSRs that clearly did not attend to the key concept of universalism.

Question 5: “Does it respond to disadvantage?”

Several of the CSRs did respond to disadvantage. For example, 3 focused particularly on Roma

populations (BG, RO, SK). The UK analysis mentions it has one of the highest proportions of children

living in jobless households and IE has a CSR to “take steps to increase the work-intensity of

households”. Child poverty is mentioned in 5 CSRs (ES, HU, IE, IT, RO) but only 2 countries (IE, ES)

receive recommendations to tackle poverty (Spain implicitly through a minimum income and family

scheme). Therefore only AT, CZ, and EE were classified as not responding to disadvantage.

21

Question 6: “Does it encourage early intervention (from an early age)?”

Recommendations for BG, RO and SK explicitly encourage intervention from an early age in

education or care. This is included in the “Whereas” for PL as well. The other recommendations are

unclear on this topic because they either deal with childcare (AT, CZ, EE, IE, UK) or early intervention

is not explicitly mentioned and the CSR targets the family (ES).

Member state

Q1. Children and parents?

Q2. Investment?

Q3. Intersectoral?

Q4. Universal?

Q5. Disadvantage?

Q6. Early intervention?

AT N Y Y Y N N

BG N Y N N Y Y

CZ N Y N Y N N

EE N Y N Y N N

ES N Y Y Y Y N

IE Y Y Y Y Y N

RO N Y N N Y Y

SK Y Y Y N Y Y

UK N Y N Y N N

Total 2 9 2 5 5 3

Table 7. Overview of questions and CSRs relating to children

Policy implications Just 3 countries (BG, RO, SK) receive a CSR to intervene early on to tackle inequalities pertaining to

children and their families. This is worrying, as early intervention is recognised as crucial in

preventing a range of developmental and health issues. Many more countries receive CSRs that imply

investments in children, universal approaches, and addressing disadvantage, but do not foresee an

intersectoral and interconnected approach targeting both children and their families; this could

hinder successful and inclusive implementation. CSRs on early intervention are ambiguous for 5

countries either because the CSR deals with childcare and because early intervention is not explicitly

mentioned (AT, CZ, EE, IE, UK) or because it targets the family (ES).

The issue of child development and child poverty is less prominent in the 2015 CSRs than in 2014. For

instance, in 2014 4 countries (AT, DE, IT, PL) received recommendations on childcare (access,

affordability, quality) but they no longer receive one in 2015. Similarly, in 2014 11 countries received

CSRs on inclusive education/early-school leaving (BE, DE, DK, ES, FR, HR, IT, MT, PL, PT & SE), but this

issue is only mentioned in 5 countries’ CSRs in 2015 (BG, HU, PL, RO, SK).

22

A separate analysis of CSRs by the European platform for Investing in Children also reveals fewer

CSRs in 2015 compared with 2014 (see Table 8)32.

Policy area Countries receiving a CSR in 2014 on child policy issues (#)

Income support BG, ES, HU, IE, IT, LV, PT, RO, UK (9)

ECEC/childcare (access, affordability, quality) AT, CZ, DE, EE, IE, IT, PL, RO, SK, UK (10)

Inclusive education/ Early school leaving AT, BE, BG, CZ, DE, DK, EE, ES, FR, HR, HU, IT, MT, PL, PT, RO, SE, SK (18)

Reconciliation MT, PL (2)

Roma BG, HU, RO, SK (4) Table 8. Overview of CSRs related to Council Recommendation on investing in children in 2014

Overall, there appears to be clear scope to improve CSRs by increasing emphasis on the role of

parents and children in sustaining and improving health. DRIVERS research suggested that positive

outcomes result from interventions that augment parental capacities (such as maternal or paternal

self-esteem, non-abusive parenting styles including nurturing and management, and parental

involvement in school). Parenting programmes that promote healthy environments and healthy

behaviours appear to be particularly effective in improving child health and well-being. The earlier

these programmes are offered, the better the outcomes are. To ensure active parental involvement

in relevant early years programmes, parents should receive support and information to understand

how to contribute to their children’s optimal development. They should also be empowered to

improve their own skills, so as to strengthen their ability to assist in their children’s learning and

development.

DRIVERs found that most policy interventions focus on the most vulnerable families, but lack

sufficient scale across the population to level up the social gradient in health. When they are

universal, they are usually not delivered with the intensity required to improve the health and

development of children with higher levels of need. Only 2 countries’ CSRs (IT, ES) responded to

disadvantage and were universal, suggesting that health equity could be improved by putting greater

emphasis on introducing, monitoring and evaluating interventions that are: 1) universal, and 2)

responsive to need. The Marmot Review explains what needs to be done to reduce health

inequalities: “To reduce the steepness of the social gradient in health, actions must be universal, but

with a scale and intensity that is proportionate to the level of disadvantage”33.

When the European Commission launched the Social Investment Package, it included a Council

Recommendation on “Investing in children: breaking the cycle of disadvantage”, which stressed the

importance of early intervention and preventative approaches. These policy tools call for a

comprehensive response that supports parents’ access to the labour market, improve access to

affordable early childhood education and care services and to provide adequate income support such

as child and family benefits, which should be redistributive across income groups. These measures

could be useful in informing CSRs.

Work–life balance is included in the challenges identified for 2 countries (IT, MT) – so there could

also be scope to address this issue more prominently in the European Semester. This could be part of

broader labour market reforms. A better work–life balance would enable families to spend more

time together and therefore have a more enjoyable and stress-free life, benefiting health.

23

Mention should also be made about the number of CSRs which refer to children and families in the

“Whereas” sections, but do not provide corresponding “Recommendations”. Such instances come

across as unhelpful and unresponsive. These types of inconsistencies could risk undermining the

entire process.

Recommendations Several steps could be taken to ensure that the 2016 Annual Growth Survey and CSRs result in

greater health equity. The European Commission and member states could:

Ensure that children and families are on the agenda of the CSRs. Children and families are

on the agenda in too few CSRs in 2015. Health is determined across the life course, and

policies and interventions to improve child health help ensure the future sustainability of

health and social systems, reducing early retirement and increasing well-being and healthy

life years.

Encourage early investment in child development in the CSRs in line with Social Investment

Package and Council Recommendation on “Investing in children: breaking the cycle of

disadvantage”. Even when children and families are on the agenda too little emphasis is

placed on investing early on. Just three countries received a CSR on early intervention in

2015. This is worrying, given that early intervention is widely considered one of the most

effective ways to prevent health and social problems.

Encourage the involvement of parents and children in policies and interventions that affect

them. As indicated by DRIVERS, interventions that appear to be successful in improving

health and reducing health inequalities involve children and their parents. Just two CSRs

provided solutions that highlighted the importance of supporting children and parents in

2015.

Ensure interventions are both universal and responsive to need, thereby implementing the

principle of “proportionate universalism”. This can be done in different ways, according to

specific policy area (e.g. childcare, early interventions, reconciliation). It does not necessarily

imply greater expenditure and could involve quality universal services supplemented by a

variety of tailored services that respond to different kinds of need.

Give proper time to implement child development reforms; do not change priorities on a

yearly basis. As shown, CSRs highlights issues pertaining to children and families more

prominently in 2014 than 2015 – though child poverty actually increased in several member

states34. Member states need time to respond to CSRs, and changing priorities on a yearly

basis will not encourage coherent action to be taken.

Address the lack of coherence between the problems identified and solutions proposed. As

described early on, many CSRs identify problems in the “Whereas” but do not propose

solutions. Aside from those instances where action has already been taken, this appears

incoherent and unhelpful.

Explore if work–life balance should be more prominent in the EU Semester and CSRs. As

argued, families play an important part in communities and in raising children; difficulties

balancing the needs of work and family life reduce the abilities of families to play these roles

effectively and could have detrimental effects on health and well-being later on in life.

Work–life balance is mentioned in only two countries’ CSRs (IT, MT), and then only in the

“Whereas” section; no country receives a corresponding recommendation.

24

4. Do the 2015 CSRs help move towards sustainable health systems?

Introduction Health systems and their financing have been included in the Semester process since it began, and

the number of health-related CSRs has increased every year until 2015 (Figure 1). In 2015 the process

was reformed to increase ownership and uptake of recommendations and the Commission further

consulted with member states, which streamlined the process and resulted in fewer issues being

analysed. This resulted in focus on key priority areas to be implemented in the short term; these

included pharmaceutical spending, administrative structures, quality and accessibility of care and the

balance between primary and hospital care. The 2015 CSRs recommend further reforms in these

areas for several member states (BG, CZ, ES, FI, FR, HR, LV, LT, RO, SI, SK).

Figure 1. Health in CSRs, 2011-2015

Links between access, primary care, community care and health promotion Health systems need to address growing demand for health services with an ageing population, the

growing prevalence of non-communicable diseases, higher rates of multi-morbidity, as well as

technological developments and the emergence of new treatments. This requires the integration of

services in health facilities, provision of community care and increased emphasis on disease

prevention and health promotion, so as to improve healthy life years. Primary care practitioners have

the potential to assist in delivering these changes by developing long-term relationships with patients

and the community. In “Health at a Glance” (2014), the OECD suggests that countries should improve

primary care to further reduce costly hospital admissions for chronic conditions35. Researchers have

recently explained the potential to include systematic prevention and intervention in non-

communicable diseases:

“In response to challenges in the health care sector, reform measures in many countries have

sought to strengthen primary care… concerning strategies to focus more strongly on

6

10

17

18

11

2011 2012 2013 2014 2015

No

. me

bm

er

stat

es

25

prevention and health promotion, primary care could potentially play a role if services are

better integrated and providers adopt a more preventive attitude”36.

The World Health Organization (WHO) defines accessibility as ‘a measure of the proportion of the

population that reaches appropriate health services’37. When it comes to equity of access, two

different aspects can be distinguished:

Horizontal equity: the extent to which individuals are treated equally and/or to which

individuals with the same needs are treated equally;

Vertical equity: the extent to which individuals are treated equitably in financing health care.

This is also the perceived “fairness” of health systems.

An equitable health service is therefore one where individuals’ access to and utilisation of the service

depends on their health state alone, and not on their socio-economic status, except in so far as that

affects their health status. Despite comprehensive health baskets, the poor can still miss out on

certain services: dental care, physiotherapy and certain mental health services if they are excluded

from basic health coverage. Countries where a relatively high percentage of healthcare costs are

covered though out of pocket payments, or through additional insurance cover, may be too

financially onerous for people on lower incomes, thereby severely restricting their access to such

services38.

Methods We use the outcomes of two FP7 research projects by EuroHealthNet (DRIVERS and GRADIENT) to

examine whether the 2015 CSRs are likely to produce health system reforms that reduce health

inequalities. Each country CSR was read and a keyword search for the term “health*” was conducted.

Questions were taken from the GRADIENT Evaluation Framework (GEF) to evaluate if the policy

actions address health inequities. To check for health promotion measures, the questions asked

were:

Does the recommendation embrace the principles of modern public health/health

promotion, e.g. a holistic approach to health, attention to the social determinants of health

inequalities, empowerment, social justice, equity, sustainable development, etc.?

Is the policy action a downstream measure, e.g. seeking to alter adverse health behaviours

such as smoking or increasing breastfeeding rates through the health sector alone?

Is the policy action a midstream measure, e.g. focusing on psychosocial factors, behavioural

risk factors and risk conditions?

Is the policy action an upstream measure, e.g. focusing on the wider circumstances that

produce ‘adverse’ health behaviours (such as social conditions, employment, macro-

environmental policies, and social justice policies)?

Does the recommendation take into consideration the quality of services and does provision

include coverage?

The CSRs are then compared to the 2014 recommendations for developmental progression.

Findings The keyword search for “health” found results for 14 member states (AT, BG, CZ, ES, FI, FR, HR, IT, LV,

LT, MT, RO, SI, & SK). Of these, for 3 (AT, IT, & MT) the reference to health systems was only in the

26

“Whereas” section. This resulted in 11 countries (BG, CZ, ES, FI, FR, HR, LV, LT, RO, SI, & SK) that had

CSRs relating to the health system in both the “Whereas” and “Recommendations” sections.

It is important to note that reducing health inequalities and improving health promotion and disease

prevention are not the explicit aims of any CSR recommendations. The majority of CSRs are classified

in the downstream measure (BG, CZ, HR, LV, LT, RO, SI, SK, ES) because they focus solely on the

financing of health systems. Bulgaria and Slovakia were classified as having midstream measures

because primary care can focus on psychosocial and behavioural risks. Only Finland was classified as

upstream for dealing with integration of health and social services in administrative reform (Table

11).

A closer analysis delivered more nuanced findings. All 11 health-related CSRs either address cost-

effectiveness (CZ, HR, IE, ES, FI, SK) health systems performance (LT), hospitals (LV), or efficient use of

resources (RO). The only exception is Slovenia where there is a recommendation on health system

and long-term care reform. For 4 countries (HR, CZ, IE, ES) the CSRs focus mostly on financial

sustainability (pharmaceutical spending for IE and ES). Low levels of funding or public investment are

referred to in the “Whereas” for BG, RO, LV, LT, while only RO is recommended to remedy the low

level of financing.

Several CSRs are classified as taking a holistic approach to health systems. In the context of the EU

Semester this was for going beyond the finances of health systems to include primary care (BG, SK),

accessibility (LV, RO) and addressing quality (FI, LV). Coverage is not addressed by any of the reforms.

However, the “Whereas” section of LV notes that high out-of-pocket payments contribute to access

to healthcare problems. When looking at more community-based models of care only BG is

recommended to strengthen out-patient care and SI in the reform of long-term care. At the same

time, this is a challenge noted in the “Whereas” section for 3 countries (AT, BG, and RO).

National health strategies are included in the “Whereas” section of 5 countries (BG, CZ, IE, RO, SK).

But only RO is recommended to implement the national health strategy.

Theme Number of CSRs

Health promotion and disease prevention 0

Mental health 0

Community care 2 (BG, SL)

Primary care 2 (BG, SK)

Access to care 2 (LV, RO)

Quality 2 (LV, FI)

Financial sustainability 4 (HR, CZ, IE, ES)

Performance of hospitals/health system 3 (SK, LT, LV)

Cost-effectiveness 6 (CZ, HR, IE, ES, FI, SK) Table 9. Areas of 2015 CSR relating to sustainable health systems

Implications

Health promotion

Four countries receive a CSR concerning poor performance or inefficient use of resources (BG, LT, LV,

RO) but there is no assessment of the underlying causes of ill health. A recent paper by DG Economic

and Financial Affairs (ECFIN)39 identified several significant causes of inefficiencies in health systems,

27

including: sub-optimal setups for delivery of care, inefficient provision of acute hospital care, fraud

and corruption in health care systems, and a sub-optimal mix of preventative versus curative care.

The report explains the potential of efficiency gains to increase life expectancy and free up resources:

“it is universally acknowledged that lifestyle factors, such as tobacco smoking, obesity, wrong

diet and lack of physical activity have a significant impact on health outcomes, increasing

demand for health services. Major chronic diseases can often be prevented through lifestyle

changes. Prevention policies may lead to a longer period of life without diseases and reduce

costs. However, the health benefits of prevention may also increase the overall life span in

such a way that especially older people can live longer but with chronic diseases… moving

resources from treatment to prevention of cardiovascular diseases or diabetes will increase

the cost-effectiveness of spending, while relying on treatment alone will be suboptimal”40.

The OECD estimates that average life expectancy could increase by about 2 years for the OECD as a

whole if healthcare resources were used more efficiently41. The authors conclude that this has the

potential to reduce the long-term rate of growth of health expenditure without compromising access

to (quality) care45. Examining the CSRs more in depth, there appears to be a contradiction between

the strong focus on cost-effectiveness, performance, and efficient use of resources and no reference

to health promotion or disease prevention. Neglecting public health and health determinants

disregards previous EU-level recognition of their positive impacts and benefits. Previously, the

Commission and the Economic Policy Committee identified better health promotion and disease

prevention in and outside the health sector as an area to make efficiency gains. This could include

measures designed and implemented jointly with other sectors that have a major impact on health,

such as education, housing, environment, employment42. In short, the cost-effectiveness of disease

prevention has been recognised by the EC, yet it is not emphasised adequately in the CSRS.

Moreover, no role is foreseen in the CSRs for improving the sustainability of health systems from

outside the health sector.

Primary care

In 2015 there are fewer references to primary care than in the previous year. In 2014, Malta received

a recommendation to improve primary care and this was also part of Poland’s analysis that year for

efficiency gains in the health system. In the context of the EU Semester, primary care is the only

midstream measure that addresses psychosocial factors and behavioural risk factors.

Public health spending in the EU

When ranked on the percentage of GDP on spending on public health, one can see noticeable

differences between member states43. For several member states there has also been a decline in

spending.

28

Figure 2. Health expenditure (% GDP) on prevention and public health services (2010, 2011, 2012)

Source: Eurostat. (2015). Health care expenditure by function.

The differences in spending on public health, and recognition that to achieve sustainable health

systems a better mix of preventative versus curative care is needed, suggests further scope to shift

resources to strengthen public health. For the European Semester, this could imply a stronger role

for preventative services and primary care. The additional references to primary care in previous

years suggest this is a feasible option.

Low levels of funding at national level could partly be addressed through appropriate use of

structural funds. Structural funds remain a largely untapped resource for investing in public health.

As identified for BG, RO, and LV, a targeted approach can be taken by the EU. Equity Action, the EU

co-funded Joint Action on Health Inequalities44, made several recommendations on how structural

funds can be used to reduce health inequalities at the regional level. To address this, public health

decision makers and professionals must adopt a strategic approach to:

0 0.1 0.2 0.3 0.4 0.5 0.6

Lithuania

Cyprus

Belgium

Greece

Poland

Luxembourg

Latvia

Croatia

Czech Republic

Estonia

Austria

Spain

Slovakia

Portugal

France

EU Average

Denmark

Bulgaria

Hungary

Slovenia

Sweden

Romania

Germany

Netherlands

Finland

Percentage of Gross Domestic Product (GDP)

EU m

em

be

r st

ate

s w

ith

dat

a av

aila

ble

2010

2011

2012

29

Raise awareness amongst colleagues at the national, regional and local level of the structural

funds as a potential co-funding mechanism for initiatives that can directly or indirectly

improve health equity.

Raise their profile vis-à-vis structural fund managers and other sectors, and make the

necessary contacts and links.

Invest in building capacities within health systems and foster health experts who understand

structural funds, as well as the social determinants of health and health equity, and who can

convey this to others.

Chronic diseases

Chronic diseases are the leading cause of mortality and morbidity in Europe45. Chronic diseases

depress wages, earnings, workforce participation and labour productivity, as well as increasing early

retirement, increasing job turnover and disability. Therefore both from the labour market and health

performance perspectives addressing health promotion and disease prevention is a win-win

situation, and not doing so is a lose-lose situation.

Mental health

Another area where there are benefits both for the labour market and efficiency of health systems is

mental health. It is estimated that 50-60% of all working days lost to illness are linked to stress and

psychosocial risks. Mental health causes further financial losses to the economy, in terms of reduced

productivity, absenteeism and presenteeism46 – which amounts to 798 billion euros annually in the

EU47. Yet this issue is not addressed in the 2015 CSRs.

Figure 3. Cost per capita of all brain disorders (€PPP 2010)

Source: European Brain Council (2012). The economic cost of brain disorders in Europe. European Journal of

Neurology, 19(1), 155-162.

A recent OECD study could also help shape how mental health is treated in the EU Semester. It found

that expenditure on mental disorders is one the highest areas of health expenditure, representing

between 5% and 18% of all health expenditures in four EU member states (CZ, HU, NL, SI)48; see

Annex 5 for overview of EU. Similarly, previous analysis published by the OECD estimates that mental

health represents 20-45% of total expenditure on healthcare. In 2015 mental health was included in

30

several countries’ national reform programmes (DK, FI, NL). As part of effort to create better

conditions for disadvantaged people in DK, “the government aims to reduce the use of ‘coercion’ in

the mental health sector by 50 per cent towards 2020”51. In the NL, in the recent reform of long-term

care, “the supervision and the protected residence of mental health care clients, were placed under

the new legislative framework, Social Support Act 2015”52. In Finland, mental health promotion was

part of the reform to reduce disability-related early retirement49.

National health strategies

As several of the “Whereas” make reference to national health strategies, further exploration could

be given to how the European Semester process can contribute to their implementation. This could

also be a way to make links between policy actions in different member states to improve health

promotion and reduce health inequalities. Creating synergies between national strategies and the

European Semester may also foster greater ownership and involvement of health practitioners.

Recommendations Several steps that could be taken to ensure that in the 2016 Annual Growth Survey and the

implementation of the CSRs result in greater health equity. The European Commission and member

states can:

Focus more on public health, health promotion and disease prevention. None of the CSRs

deal with these measures.

There is further scope to focus more on primary and community care, quality and equity.

Only 6 CSRs address on primary care, quality and access in 2015 despite their importance in

helping sustain high levels of health, and therefore high levels of employment and the ability

to work to retirement; 2 countries (FI, LV) received a recommendation on quality, 2 countries

(BG, SK) received a recommendation on primary care, and 2 countries (LV, RO) received a

recommendation on accessibility.

Continue to emphasise the importance of equitable access to healthcare and conduct

further analysis on coverage rates. Despite comprehensive health packages, the poor may

still miss out on services. These can include dental care, physiotherapy and certain mental

health services if they are often excluded from the basic package. Taking out additional

insurance cover may be financially too onerous for people on lower incomes, thereby

severely restricting their access to such services50.

Further integrate the reduction of health inequalities and promotion of well-being in the

European Semester. Health inequalities and mental health were not the focus of any CSRs in

2015.

Conduct in-depth analysis of the underlying causes of ill health in countries with poor

performing health systems and low health outcomes. This is important, as the CSRs took

note of poor performance of health systems or inefficient use of resources in 4 countries (BG,

LT, LV, RO).

Further explore how the EU Europe 2020 strategy can support (sub-)national health

strategies and align with the WHO-Europe Health2020 strategy. National health strategies

were included in the “Whereas” section of 5 countries (BG, CZ, IR, RO, SK). But only RO was

recommended to implement the national health strategy.

31

Build capacity in member states to access structural funds for reducing health inequalities

Particular efforts are needed in countries with low levels of public health financing. This

remains a largely untapped area for investing in public health.

32

Annex 1. Additional tables, figures and annexes

Table 10. Pension data

(m=men; w=women; HLY=healthy life years; LE=life expectancy; diff = difference; SR=statutory retirement age; ER=early retirement)

33

Figure 4. Statutory retirement age, healthy life years and life expectancy, 2012, men

34

Figure 5. Statutory retirement age, healthy life years and life expectancy, 2012, women

35

Figure 6. Healthy life years & early retirement, women, 2012. Malta is omitted as no figures available for HLY

EL CZ

SI

BG

SK

IT

CY

PL

HU

LT

FR

BE

UK

EU28 AT

IE

HR

SE

NL LV

RO

DE

FI

ES

DK

EE

LU

PT

R² = 0.0025

50

55

60

65

70

75

0 5 10 15 20 25 30 35 40 45

He

alth

y Li

fe Y

ear

s

Early retirement for health reasons, %

36

Figure 7. Healthy life years & early retirement, men, 2012

EL

MT

CZ

IT BG

FR

SE

SI

BE

CY NL

LU

HU

UK

EU28

IE

SK

LV

PL

ES

LT

DK

FI DE RO

PT AT

HR

EE

R² = 0.3306

50.0

55.0

60.0

65.0

70.0

75.0

0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 50.0

He

alth

y Li

fe Y

ear

s

Early retirement for health reasons, %

37

Annex 2. Pensions, healthy life years and statutory retirement ages in 2015 CSRs

38

Annex 3. Table of 2014 child and family CSRs

Member state

Are children or their families on the agenda?

“Whereas” section

“Whereas” and “Recommendations” sections

Only

AT Y

BE N

BG Y

CZ Y

DE N

DK N

EE Y

ES Y

FI N

FR N

HR N

HU Y

IE Y

IT Y

LT N

LU N

LV N

MT Y

NL N

PL Y

PT N

RO Y

SE N

SI N

SK Y

UK Y

TOTAL Y=13 / N=13 = 4 = 9 Table 11. Children and families in CSRs

39

Annex 4. Findings from previous research on equitable access to healthcare in Europe

Further research into inequity of access to healthcare services carried out at the request of DG EMPL

in 2008 explored access barriers of particular relevance to people at risk of social exclusion51. It also

highlighted the impact of public and private financial resources in breaking the circle that exists with

regard to poverty, ill health and inequitable access to high quality services:

Across EU member states, coverage of basic health care costs is universal and mandatory for

everybody with a residency status, and organised under public programmes irrespective of

ability to pay. Those without public health coverage, however, are often people at risk of

poverty and social exclusion, such as migrants and people depending on social assistance.

This includes people with limited capacity to organise and regularly pay for social –never

mind additional- health insurance in those countries where this is an individual responsibility.

Health baskets offered within the scope of public programmes are fairly comprehensive, but

vulnerable people may still miss out on certain services: dental care, physiotherapy and

certain mental health services are often excluded from basic packages. Taking out additional

insurance cover may be a financial step too far for people on lower incomes, thereby

severely restricting their access to such services.

Organisational barriers, such as waiting lists or limited surgery opening hours also have a

relatively greater impact on people at risk of poverty. If waiting lists are long, they usually

lack the means to turn to alternative providers in the private sector. People in blue collar jobs

and/or working in shifts may have less flexibility to attend surgery hours. When they feel

their job is at risk they may delay seeking care.

Groups at risk of poverty and/or social exclusion are disproportionately affected by the

financial burden of cost-sharing arrangements. In those countries where a relatively high

percentage of healthcare costs is covered though out-of-pocket or informal payments this

may result in catastrophic expenditures for groups at the lower end of the socio-economic

spectrum as these forms of funding are regressive. This also impacts negatively on the uptake

of necessary services. In some countries, special arrangements exist to compensate people

on lower incomes for the relatively high costs incurred. In those cases, clauses that provide

general exemption rules are more helpful than setting payment ceilings, as the latter may

require-complex- paperwork to reclaim costs and people still have to pay the full costs

upfront.

Geographical barriers are especially relevant to older people and those with limited mobility.

Such barriers may be exacerbated in rural areas, where poverty risk also tends to be higher.

Inappropriate health beliefs and limited levels of health literacy -the ability to understand

how to make sound health and health service choices and to communicate with health

professionals- may impose additional access barriers.

40

Annex 5. Health in the CSRs – Recommendation & Whereas sections

Member state Whereas section

Austria Austrian healthcare spending ranks amongst the highest in the EU. The ongoing healthcare reform (2013-2016) is aimed at stabilising it as a proportion of GDP as of 2016. However, even if the reforms are successful, the fiscal sustainability and efficiency of the healthcare system still face structural challenges. Measures should be taken now with regard to the period after 2016. For example, more patients should be treated in multidisciplinary primary outpatient care settings and the average length of stay for inpatient treatment should be lowered further.

Bulgaria The Bulgarian healthcare system faces several major challenges, including poor health outcomes, low funding and serious inefficiencies in the use of resources. Life expectancy is considerably below the EU average and life expectancy at birth is among the lowest in the EU. The system continues to be based on an oversized hospital sector. Although funding of primary and

Member state Recommendation section

BG Improve the cost-effectiveness of the health care system, in particular, by reviewing the pricing of health care and strengthening outpatient and primary care.

CZ Further improve the cost effectiveness and governance of the healthcare sector.

ES Improve the cost-effectiveness of the healthcare sector, and rationalise hospital pharmaceutical spending.

FI Ensure effective design and implementation of the administrative reforms concerning municipal social and healthcare services, with a view to increasing productivity and cost-effectiveness in the provision of public services, while ensuring their quality.

IE Take measures to increase the cost-effectiveness of the healthcare system, including by reducing spending on patented medicines and gradually implementing adequate prescription practices. Roll out activity-based funding throughout the health system.

HR Tackle the fiscal risks in healthcare.

LT Address the challenge of a shrinking working-age population by improving the labour market relevance of education, increasing attainment in basic skills, and improving the performance of the healthcare system.

LV Take action to improve accessibility, cost-effectiveness and quality of the healthcare system and link hospital financing to performance mechanisms.

RO Pursue the national health strategy 2014-2020 to remedy issues of poor accessibility, low funding and inefficient resources.

SK Improve the cost-effectiveness of the healthcare sector, including by improving the management of hospital care and strengthening primary healthcare.

SI By end of 2015 adopt a healthcare and long-term care reform.

41

outpatient care has slightly gained significance in nominal terms in recent years, it is still quite limited. The healthcare fund is contractually obliged to reimburse hospitals for treatments at predefined prices, which is incentivising hospitals to provide inadequately targeted medical care. A National Health Strategy was adopted in 2014 but it lacks a clear implementation plan.

Croatia As regards the healthcare sector, recurrent arrears continue to pose fiscal risks. Measures have been initiated to rationalise hospital funding, but there are implementation risks. The 10% budget increase covers funding needs only partially; further efficiency savings will have to be made to ensure the full elimination of arrears by 2017.

Czech Republic Although some measures have been taken to improve the cost efficiency and governance of the healthcare sector, limited progress has been made in this area. Indicators used to measure the performance of the hospital sector show that medical treatment is not always delivered in a cost-efficient way, while the allocation of resources is hampered by ongoing difficulties in rolling out a reimbursement system for costs incurred by hospitals. There are also signs that general practitioners are not adequately fulfilling their role as gate-keepers. Public procurement in the healthcare sector suffers from a high incidence of irregularities, suggesting insufficient guidance and supervision.

Finland The Government’s bill on the reform of social and healthcare services was presented to parliament in December 2014, but no solution was found to balance the administrative model of large municipal coalitions with the autonomy of single municipalities guaranteed by the Constitution before the parliamentary elections in April 2015, and the bill lapsed.

Ireland Public expenditure on healthcare is comparatively high even though population health status indicators are generally no better than in the rest of the EU. Efficiency gains have been achieved in recent years. However, the health system needs deeper structural reforms to contain expected cost increases and maintain favourable health outcomes in the face of an ageing population. Ireland aims to introduce a single-tier universal health insurance scheme in the medium term and is implementing reforms under the Future Health strategy. Intermediate steps are being pursued in the introduction of universal health insurance to address some of the pressing challenges and improve cost-effectiveness. Effectively rolling out e-health tools, activity-based funding and improved prescription practices have significant potential to increase cost-effectiveness. At the same time, the potential remains to reduce public spending on pharmaceuticals, in particular patented medicines, which is well above the EU average.

Lithuania Lithuania is facing a substantial fall in the working-age population, driven by demographics, migration and poor performance of the healthcare system. The number of hospital beds per capita remains high as compared with the rest of the EU, suggesting there may be imbalances in the provision of healthcare. At the same time, total public investment in the healthcare sector remains low. The reported high frequency of informal payments for healthcare services, together with concerns about corruption in public procurement procedures for medical goods, demonstrate the need to improve the governance of the healthcare system.

Latvia Low public healthcare financing and high out-of-pocket payments, inadequate focus on performance incentives and efficiency, lack of care coordination result in reduced access of large proportion of the population. There is significant room to increase the cost-effectiveness and quality of the system

42

and to link hospital financing to performance based mechanisms. The quality of public services would benefit from stronger measures against conflict of interest and corruption, especially in vulnerable sectors such as public procurement, construction and healthcare.

Romania The Romanian healthcare system is characterised by poor results of treatment, poor financial and geographical accessibility, low funding and inefficient use of resources. There is high reliance on in-patient services and the system suffers from the extensive inefficient hospital network, the weak and fragmented referral networks, and the low proportion of spending directed to primary healthcare. In addition, the widespread use of informal payments in the public healthcare system further reduces the accessibility, efficiency and quality of the system. Various measures and healthcare reforms that have been introduced have narrowed the funding gap and improved the standard and efficiency of services. The National Health Strategy 2014-2020, which sets the strategic base for health sector reforms, was approved in December 2014 and is now to be implemented. The Ministry of Health and the National Health Insurance House are considering various measures to improve the system for financing healthcare.

Slovakia The overall level of efficiency of the Slovak health system is weak, and it performs poorly when compared with the rest of the EU. The government adopted a new strategy for health for 2014-2020, in order to try to address the shortcomings of the national healthcare system. The strategy is being implemented, but most measures are not yet in force.

Slovenia At the end of 2013, the government adopted a blueprint for long-term care reform but the adoption of the legislation implementing the reform has been postponed to the end of 2015 in order to allow prior decisions on health insurance reform including the question of sources to finance overall healthcare and long-term care. Age related expenditure on long-term care can be contained by targeting benefits to those most in need and by refocusing care provision from institutional to home care.

Spain In 2014, Spain also made some progress on identifying proposals to rationalise healthcare, education, and social spending at regional level, although these were not finally adopted. However, draft legislation to introduce a spending rule on pharmaceutical and healthcare regional spending is currently before parliament.

43

Annex 6. Mental Health Spending across the EU

44

Table 12. Mental health spending across the EU and Norway

Source: European profile of prevention and promotion of mental health (EuroPoPP-MH), 2013.

45

Annex 7. Percentage of total public expenditure on mental health

Figure 8. Percentage of total public expenditure on health spent on mental health

Source: OECD (2014) - Making Mental Health Count: The Social and Economic Costs of Neglecting Mental

Health Care.

46

Notes and references

1 Other factors may well have been more important in causing and sustaining the crisis, such inadequate

regulation of financial markets and a response to the crisis that massively increased member states’ indebtedness (i.e. as a result of the estimated 4.5 trillion euros given in state aid to financial institutions between 2008 and 2011). 2 “The European Union, 'social Europe' and the macro-drivers of health”, in DRIVERS newsletter #3, available at:

http://us4.campaign-archive2.com/?u=46a1701c5a84634d16800ef0b&id=3530810ed3. 3Accessible at: http://ec.europa.eu/europe2020/making-it-happen/country-specific-

recommendations/index_en.htm. 4Directorate-General for Internal Policies – Economic Governance Support Unit (EGOV), 2015. The legal nature

of Country Specific Recommendations. Available at: http://www.europarl.europa.eu/RegData/etudes/ATAG/2014/528767/IPOL_ATA%282014%29528767_EN.pdf. 5 European Commission, 2015. The 2015 Ageing Report EUROPEAN ECONOMY. Available at:

http://ec.europa.eu/economy_finance/publications/european_economy/2015/pdf/ee3_en.pdf. 6 See p127, http://ec.europa.eu/economy_finance/publications/european_economy/2015/pdf/ee3_en.pdf.

7 See http://ec.europa.eu/social/main.jsp?langId=nl&catId=89&newsId=2129&furtherNews=yes.

8 See http://ec.europa.eu/economy_finance/publications/european_economy/2013/pdf/ee-2013-4-04.pdf.

9 For example, concerning increases in pension ages, see p31 of

http://ec.europa.eu/economy_finance/publications/european_economy/2015/pdf/ee3_en.pdf. 10

See http://ec.europa.eu/eurostat/statistics-explained/index.php/Social_protection_statistics_-_pension_expenditure_and_pension_beneficiaries. 11

See http://ec.europa.eu/eurostat/statistics-explained/index.php/File:Expenditure_on_pensions,_2012_%28%25_of_GDP%29_YB15.png. 12

See the proposed new EU structural indicator Healthy Life Years (HLY) is a http://www.healthy-life-years.eu/. http://ec.europa.eu/health/indicators/healthy_life_years/hly_en.htm. 13

Available at: http://ec.europa.eu/economy_finance/publications/european_economy/2014/pdf/ee8_en.pdf. 14

See http://www.eurohex.eu/pdf/Reports_2014/2014_TR6%201_Monitoring%20socioeconomic%20differentials%20in%20HLY%20across%20Europe.pdf. 15

See http://www.socialsecurity.fgov.be/docs/nl/publicaties/conferences/100212/100212-hly-final-report.pdf. 16

See http://ec.europa.eu/eurostat/cache/metadata/DE/hlth_hlye_esms.htm and http://ec.europa.eu/eurostat/cache/metadata/Annexes/hlth_hlye_esms_an2.pdf for further details about accuracy and comparability of HLYs. 17

HEIDI can be accessed from: http://ec.europa.eu/health/indicators/echi/list/echi_40.html. 18

HEIDI can be accessed from: http://ec.europa.eu/health/indicators/echi/list/echi_40.html. 19

Available at: http://ec.europa.eu/economy_finance/publications/european_economy/2014/pdf/ee8_en.pdf. 20

See “lfso_12reasnot” dataset, available at: http://ec.europa.eu/eurostat/web/lfs/data/database. 21

All CSRs and other documents available from: http://ec.europa.eu/europe2020/making-it-happen/country-specific-recommendations/index_en.htm. 22

These keywords were chosen based on a review of previous years’ CSRs. 23

Country codes follow the format of the EU’s inter-institutional style guide: http://publications.europa.eu/code/pdf/370000en.htm. 24

See http://www.health-gradient.eu. 25

DRIVERS Childhood Development Policy Bried. Available here: http://health-gradient.eu/wp-content/uploads/2015/02/DRIVERS_Policy_Brief_Early_Childhood_rel2.pdf. 26

See http://www.ohchr.org/en/professionalinterest/pages/crc.aspx 27

Pillas D, Marmot M, Naicker K, Goldblatt P, Morrison J & Pikhart H (2014). Social inequalities in early childhood health and development: a European-wide systematic review. In: Pediatric Research, 76(5), 418-424. DOI: 10.1038/pr.2014.122. 28

People at risk of poverty or social exclusion. Eurostat. http://ec.europa.eu/eurostat/statistics-explained/index.php/People_at_risk_of_poverty_or_social_exclusion.

47

29

International Federation of Red Cross and Red Crescent Societies (2013) Think Differently. Humanitarian impacts of the economic crisis in Europe https://www.ifrc.org/PageFiles/134339/1260300-Economic%20crisis%20Report_EN_LR.pdf. 30

Morrison J, Pikhart H, Ruiz M & Goldblatt P (2014). Systematic review of parenting interventions in European countries aiming to reduce social inequalities in children’s health and development. In: BMC Public Health, 14:1040. DOI: 10.1186/1471-2458-14-1040. 31

Davies, J., & Sherriff, N. (2012). The gradient evaluation framework (GEF): A European framework for designing and evaluating policies and actions to level-up the gradient in health inequalities among children, young people and their families. The Gradient Evaluation Framework (GEF). See http://www.equityevidence.eu/. 32

See http://europa.eu/epic/docs/2014-final-csrs-on-inv-children.pdf. 33

“Fair Society, Healthy Lives – Strategic Review of Health Inequalities in England post 2010”. 34

Child poverty increased in the EU28 from 23.7 in 2010 to 24.5 in 2013. Eurostat. Eurostat (ilc_peps01). 35

OECD (2014), Health at a Glance: Europe 2014, http://www.oecd.org/health/health-at-a-glance-europe- 23056088.htm. 36

Kringos DS, Boerma WGW, Bourgueil Y, et al. Building Primary Care in a Changing Europe. Copenhagen: World Health Organization on behalf of the European Observatory on Health Systems and Policies (In Press); 2012. 37

WHO Regional Office for Europe 1998, Terminology – A glossary of technical terms on the economics and finance of health services. Available at: http://www.euro.who.int/__data/assets/pdf_file/0014/102173/E69927.pdf. 38

Huber, Manfred, et al. "Quality in and equality of access to healthcare services." (2008): 160. 39

European Commission. 2015, June. European Economy Economic Papers 549. Efficiency estimates of health care systems. Available at: http://ec.europa.eu/economy_finance/publications/economic_paper/2015/pdf/ecp549_en.pdf. 40

AcademyHealth (2012), "The Economics of Prevention", Policy Brief. Available at: http://www.academyhealth.org/files/FileDownloads/RI_Econ_Prevention.pdf. 41

Joumard I., André C., and Nicq C. (2010), "Health care systems: Efficiency and institutions", OECD Economics Department Working Papers No. 769. 42

EPC-European Commission, Joint Report on health systems. (2010). Available at: http://europa.eu/epc/pdf/joint_healthcare_report_en.pdf. 43

Eurostat. (2015). Health care expenditure by function. 44

See http://fundsforhealth.eu/wp-content/uploads/2013/11/Final_EA_Regional_SF_Review_Report.pdf. 45

WHO (2010), Tackling Chronic Disease in Europe - Strategies, interventions and challenges. Available at: http://www.euro.who.int/__data/assets/pdf_file/0008/96632/E93736.pdf. 46

See http://www.keepeek.com/Digital-Asset-Management/oecd/social-issues-migrationhealth/mental-health-and-work_9789264124523-en#page1. 47

Olesen, J., Gustavsson, A., Svensson, M., Wittchen, H. U., & Jönsson, B. (2012). The economic cost of brain disorders in Europe. European Journal of Neurology, 19(1), 155-162. Available at: http://www.europeanbraincouncil.org/pdfs/Publications_/Cost%20of%20Disorders%20of%20the%20Brain%20in%20Europe%20-%20economic%20costs%20-%20EurNeuro2012.pdf. 48

OECD (2014) - Making Mental Health Count: The Social and Economic Costs of Neglecting Mental Health Care. 49

The Finnish Government, 2015. The National Reform Programme Finland 2015. Available at: http://ec.europa.eu/europe2020/pdf/csr2015/nrp2015_finland_en.pdf. 50

Huber, Manfred, et al. "Quality in and equality of access to healthcare services". (2008): 160. 50

European Commission, 2015. European Economy - Efficiency estimates of health care systems, 2015. Available at: http://ec.europa.eu/economy_finance/publications/economic_paper/2015/pdf/ecp549_en.pdf.

51The Danish Government, 2015. The National Reform Programme Denmark 2015. Available at

http://ec.europa.eu/europe2020/pdf/csr2015/nrp2015_denmark_en.pdf. 52

The Ministry of Economic Affairs, 2015. National Reform Programme 2015 The Netherlands. Available at http://ec.europa.eu/europe2020/pdf/csr2015/nrp2015_netherlands_en.pdf.